GW1-2022-08999_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD(GW 1) For Internal Use On Pi slit Form
1.Well Contractor Information:
David Hardy 14.WATER ZONES
Well Contractor Name T ;,.� FRO jM�(t DESCRIPTION
- 17
NC Well Contractor Certification Number S t P v 2022 ft. R.
Aqua Drill, Inc. 15.OUTERCASING formulHcasedwelts ORLINEIt tfa "Iicabh
q FROM TO DIAMETER THICKNESS 11 1 i [�/ MATERIAL
:`':,^ (,R`l �y ft l7 ft S. in.
Company Name V / {��
�; to /3 , a f
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit 5 yv Q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.U1C,County;State,Variance,etc-) ft. ft.
3.Well Use(check well use): ft. % in
[eft'
Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SIATSTZE THICKNESS MATERIAL
�Municipal/PubGc it it in.
hermal(Heating/Cooling Supply) sidential Water Supply(single)
strial/Commercial ft ft. rrr
Residential Water Supply(shared) 18.GROUT
tjon
FRO[it TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: U ft. tt .�
toring Recovery ft ft
on Well:
fer Recharge Groundwater Remediation tt' ft.
fer Storage and Recovery Salinity ganger FRSANDlGRAVEL PACK MaFROat TO MATERIAL EMPLCEMETHOD
er Test []Stotmwater Drainageftimental Technology oSubsidence Control fr, ftermal(ClosedLoop) OTracer 20.DRILLING LOG attachadditionalsheetsifnecessaermal(Heating/Cooling Retum �1i Other(ex lain under#21 Remarks) EOM TO DESCRIPTION color,6ardna r,sofUrock w Sim gcGl
4.Date Well(s)Completed: -25'2-1 Well ID# � fr. FL ft Zcj `I
5 AYUGs C K
52.Well Location: It. D• 13 j C Amy i V r
ft. ft.
Facility/OwnerName Facility ID#(ifapplicable) ft• ft.
ft. ft
Physical Address,City,and Zip ft, ft
ft.g yue e— 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N W ✓ j� q
6.Is(are)the well(s)pkermanent or oTemporary atgnatrue of c.ertified'Well Contractor I Date 3
��j By signing this form.I hereby centA,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or dJ9hlo with lSA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
(this is a repair,fill out blown well construction ih johrnation anted a Plain the nature ofthe COPY ofthis record has been provided to the well owner.
repair under#21 remarks section oral:the back ofthisjorm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
s SUBMITTALINSTRUCTIONS
9.Total well depth below sand surfacer (ft)For multple wells list all dept 24a.For All Wells: Submit this form within 30 days of completion of well
u ijdiQerent(example-3@200'and 2@100�
construction to the following:
10.Static water level below top of casing: 5 G (ft)ljwater level is above casing,use"+^ Division of Water Resources,Information Processing Unit,
11.Borehole diameter:
1617 Mail Service Centeir,Raleigh,NC 27699-1617
, (in).
t� 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: y Y/I izi above,also submit one copy of this form within 30 days of completion of well
(Le,auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_J 0V Method of test i 24c.For Water SuoDly&Injection We11s: In addition to sending the form to
j,�''j' � t. the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:- Amount: 1 Q "- completion of well construction to the!county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016